| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,223 |
2,214 |
$198K |
| D0120 |
Periodic oral evaluation - established patient |
2,313 |
2,299 |
$181K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,515 |
2,509 |
$166K |
| D1120 |
Prophylaxis - child |
1,990 |
1,981 |
$89K |
| D0210 |
Intraoral - complete series of radiographic images |
1,538 |
1,532 |
$74K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,567 |
3,392 |
$71K |
| D4341 |
|
824 |
253 |
$57K |
| D0274 |
Bitewings - four radiographic images |
2,529 |
2,518 |
$53K |
| D4910 |
|
688 |
684 |
$53K |
| D0350 |
|
5,596 |
2,055 |
$52K |
| D1206 |
Topical application of fluoride varnish |
2,293 |
2,284 |
$40K |
| D1351 |
Sealant - per tooth |
1,207 |
293 |
$39K |
| D9430 |
|
874 |
860 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,907 |
1,899 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,766 |
1,746 |
$21K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
36 |
28 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
170 |
$17K |
| D2740 |
Crown - porcelain/ceramic |
29 |
25 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
249 |
153 |
$13K |
| D1310 |
|
116 |
116 |
$5K |
| D9993 |
|
51 |
51 |
$3K |
| D1320 |
|
184 |
184 |
$3K |
| D0601 |
|
12 |
12 |
$180.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$156.00 |